CDC updates Ebola guidelines with stricter protocols

A nurse and a doctor demonstrate the decontamination procedure as part of ebola treatment at a hospital in Germany. Photograph by Sean Gallup—Getty Images

This post is in partnership with Time. The article below was originally published at Time.com.

By Alexandra Sifferlin, TIME

From now on, health care workers treating Ebola patients must wear full-body coverage with no skin showing and must undergo significant training prior to treating patients, the CDC announced Monday.

“We may never know exactly how [Dallas infections happened], but the bottom line is the guidelines didn’t work for that hospital,” said Dr. Tom Frieden in a press conference announcing the update of the CDC’s recommendations for caring for Ebola patients and wearing personal protective equipment (PPE). Prior to the three Ebola infections in Dallas, including two health care workers, the CDC did not recommend full body coverage for Ebola, but instead recommended at least gloves, a gown, eye protection and a face mask. That has changed, in light of the two health care worker infections at Texas Health Presbyterian Hospital.

The new guidelines have three additions:

1. Prior to working with Ebola patients, health care workers must be repeatedly trained and demonstrate competency in treating a patient with Ebola, especially putting on and taking off PPE. “Facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment,” the CDC said in a statement.

2. When wearing PPE, no skin can be exposed. The CDC is providing two options for the PPEs, since the University of Nebraska Medical Center and Emory University Hospital, which have both successfully treated Ebola patients, use different versions. Googles are no longer recommended. The recommendations for PPE are now the following:

Double gloves

Boot covers that are waterproof and go to at least mid-calf or leg covers

Single use fluid resistant or imperable gown that extends to at least mid-calf or coverall without intergraded hood.

Respirators, including either N95 respirators or powered air purifying respirator (PAPR)

Single-use, full-face shield that is disposable

Surgical hoods to ensure complete coverage of the head and neck

Apron that is waterproof and covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea

3. Every step of putting on and taking off PPE must be supervised by a trained observer. There should also be designated areas for where PPE are taken on and off.

“It’s hard to care for Ebola, so every aspect… needs to be overseen,” said Frieden in the press conference, adding that hospitals should limit personnel in health care rooms and should limit procedures to only those that are essential.

The CDC is increasing health care worker training across the country as well as sending out training videos, but Frieden argues that there is no alternative for hands-on training, especially taking on and off PPEs. “We agree with the concern of health care workers,” said Frieden citing anxiety from health care workers nationwide that they felt unprepared for treating patients with Ebola. The new recommendations will be effective immediately, though the CDC does not have the regulatory authority to make hospitals follow the guidelines, Frieden said. The recommendations should be available online later Monday evening.

Earlier on Monday, a Dallas County Judge confirmed that 43 of 48 contacts of Thomas Eric Duncan were considered no longer at risk after the 21-day incubation period passed, and Nigeria was declared Ebola-free.